My doctor has no idea I had a second kid... four months ago.

I see my PCP (maybe) once a year - and I never mentioned or reached out to them that our family was about to have a second child... it never even crossed my mind. What prompted this thought is that in hindsight, the system that's supposed to catch me if I fall apart or have an issue has no record that this event even happened.

We keep calling this a gap in maternal health *(which there's absolutely a gap in maternal health for the years postpartum) but I think we might be naming it wrong. The gap isn't only mothers. It's the family unit, and we have a healthcare system that barely acknowledges the family as a whole.

Brodotype: What was the moment you realized the system that's supposed to take care of you has no idea what's actually happening in your life?

Brody: I was in therapy talking through the last few months about becoming a second time father and it kind of landed sideways on me: my primary care doctor doesn't know I have a second child - and that made me feel... isolated.

Having a child is arguably the biggest disruption to my physical and mental health I've had in years (since the first one). Sleep, stress, money, my marriage, my sense of who I am, all of it moving at the same time, and the record that's supposed to represent me as a patient doesn't have a trace of it.

When my son was born there was plenty of documentation but it all went into my wife's chart, and his chart. Mine didn't change at all!

I've learned it goes deeper than someone forgetting to update a file. Did you know the diagnostic code for postpartum depression, F53.0, lives in a block called "mental and behavioral disorders associated with the puerperium."? (Puerperium = the six-week period following childbirth when the mother's body transitions back to a non-pregnant state). There is no version of that code for me. Even the one screening a father can sometimes get, which is my son's pediatrician asking me how I'm doing at a well visit, gets billed as a caregiver assessment for the benefit of the patient, and the patient is my son. So if somebody does ask me how I am... the answer goes in my infant's file.

It's not that nobody's looking or paying attention -- if they did look, it wouldn't be anywhere....

What that does to me is kind of subtle and a little corrosive. I didn't get turned away from anything. That would at least mean there was a system to get turned away from, or ignoring something... It's more that there's no path to start down. The system didn't acknowledge that an event happened, so nobody acknowledged what might follow it, which means the whole thing rests on me being self-aware enough to raise my hand if I may have an issue and then knowing where to go (which is still kind of a gray area).

Brodotype: You keep saying an "event" happened to you. What actually happened, physically?

Brody: This is the part I didn't know... but thankfully, one of my favorite podcasts (Startup Dad) came through with a timely episode.

Darby Saxbe runs a lab at USC that's been scanning men's brains before and after their partners give birth. In her 2024 study she imaged 38 first-time fathers during the pregnancy and again around six months after, and on average they lost about 0.9% of their total cortical volume, spread across the frontal, parietal and temporal lobes on both sides. Something in there gets pruned and reorganized when you become a father. She calls it neuroplasticity ("dad brain") - also the title of her book.

Testosterone does something similar, apparently. There's a long-running study out of the Philippines that followed 624 men for four and a half years, and the ones who became fathers dropped a median 26% in waking testosterone and 34% in the evening, significantly more than the men who stayed single. It also seems to scale with putting in the hours as a dad (which we likely aspire to do more than ever)... the research showed that fathers doing three or more hours of childcare a day had lower testosterone than fathers who weren't involved at all.

So having a kid, as a man, is a measurable physiological event - which sure... makes a ton of sense - but I'm not sure I would have thought to the extent (maybe because there's not enough data or conversation around it).

And then there's the finding that I think should have set off an alarm somewhere. In Saxbe's study, the men whose brains changed the most were the ones who were most bonded to their babies and most likely to have planned to take leave. The same group also happened to be the ones with the worst sleep, and the highest depression, anxiety and distress at six and twelve months. Her paper says the changes "might reflect not only greater parenting engagement but also increased mental health risk in new fathers."

Which means the dads doing it the way we now say it should be done are the dads most at risk. The very thing we're telling men to be, present and involved and hands-on, appears to have a cost, and we measure that cost in exactly zero clinical settings.

Still... nothing in my chart and the only clinicians who know are my in-laws, the guy I play Fantasy Hockey with, and my therapist (there's more... I mean I am in Healthtech - but you get my drift).

Brodotype: If a father falls apart after a birth, who is supposed to notice?

Brody: IT ME!!!

I did some digging (with Claude's help) and the biggest meta-analysis on this is Paulson and Bazemore in JAMA, 43 studies and 28,000 people, and they put depression in fathers at 10.4% across the first year, with a peak of 25.6% between three and six months… WHAT!?

Quincy is four months old. I'm standing dead center of that window and nobody in the healthcare system has asked me one question about it.

The guidelines explain why - The USPSTF recommendation on perinatal depression covers "pregnant and postpartum persons." ACOG's covers "pregnant or postpartum individuals." Fathers didn't get excluded from those documents so much as never written into them. The American Academy of Pediatrics is the only US body that mentions us at all, and what it says is that at the six-month well visit a pediatrician might consider screening the partner. And even then the tool used is the Edinburgh scale which was built and validated on women and only women.

What that looks like from the inside is something Kevin Maguire described on another episode of Startup Dad. He'd moved to Barcelona, left Google, and his second kid arrived in 2019, and he couldn't feel anything. Not sadness... more like an absence - which is exactly what I was feeling the last four months. He'd take the dog out, walk far enough that nobody from the house would come find him, sit on a bench and cry, and the question he was asking himself was why he didn't love this child, or feel the way he did with his first.

So he did what any of us would do, which is Google it - to no avail. He texted friends, and they all said their second baby was great... family life was good for them. And then at some point a combination of words surfaced a doctor's essay that listed every symptom he had under three words he'd never seen together before: paternal postpartum depression. He described the feeling as a strange kind of relief, because if this was a thing, then maybe it explained what was happening to him. That was 2019, and what he found in the literature was thin. His summary was that it's somewhere between 5% and 25% of new dads, but nobody actually knows, because we're not screening for it.

To be clear - I'm not sure I experienced paternal postpartum depression (but maybe I did and my existing fluoxetine prescription worked its magic)... but the fact that most men wouldn't even consider it is the thing that is wild to me.

Kevin also talked about interviewing a woman who'd gone through IVF, where the whole apparatus checked on her constantly for months, on her and on the baby, and who realized afterward that at no point had anyone asked her husband how he was doing.

I don't think that's malice, and I'm not even sure it's neglect.... There's just no box on any form or any billing code where asking that question makes it worth a clinicians time (besides you know... caring).

And I'll own my part of it - even after a decade of therapy, I'm bad at this. Men my age (37 going on 23) weren't raised to be self-aware, much less identify when we might need to ask for help. We didn't get the vocabulary or the permission. I think that's changing and fast, but I'm still a product of the version that came before, and of those who came before, for millennia. A system that only works if I volunteer is never going to work for those who don't know.

Brodotype: The picture of what a father is supposed to be seemed to change faster than almost anything. What did we build to support that?

Brody: Nadda. That's the short answer, but I don't want to move past it too quickly.

Most of what I know here comes from Kevin Maguire, who writes The New Fatherhood and has spent five years documenting what he calls a monumental shift in what it means to be a dad. His framing of the old model is the cleanest I've heard. Provide, protect, preside. Three anchors. (Worth being accurate about this: after looking it up that exact phrasing traces back to a 1995 religious proclamation, not to any fatherhood research, but it names something real that most American men inherited whether they wanted it or not.)

His argument is that all three have quietly stopped working. Provide: in about a third of US marriages men and women earn the same, and in roughly a sixth the woman earns more. Protect: men are 10 to 15% bigger, which mattered when the threat was another tribe, and is worth nothing against cyberbullying and body dysmorphia and whatever his twelve-year-old is looking at on her phone. Preside, which is "wait till your father gets home," is a model most of us have actively decided not to repeat.

And that's why the TV stuff isn't trivia(l). Maguire traces the arc from the stoic advice-giver to decades of the bumbling dad who causes all the family's problems (Homer, who as he points out only stopped strangling his son about five years ago), then some real warmth with Phil Dunphy, and now Bandit. What makes Bandit different is pretty specific. Nobody knows what Bluey's parents do for work but they know they do, because work isn't what the show is about. It's about presence. He's there, he plays, and he gets things wrong in front of his kids.

I'll be fair to the research, because it complicates the story. A content analysis of 34 sitcoms from 1980 to 2017 found fathers portrayed as more comedically incompetent in the later decades, not less. So Bandit isn't the top of a wave. He's a break from the pattern. Which I think makes the reaction to him more interesting, not less, because the demand was clearly sitting there unmet the whole time.

Maguire says about 20% of the mail he gets about Bandit is negative, and it's always the same complaint: unattainable, nobody can play with their kids that much. His response?... thank god somebody's raising the bar.

Mine is a little different and less generous. They're right that it's unattainable, but not because the bar is too high. It's because nothing in our system was built to make it reachable. 27% of US civilian workers have access to any employer-paid family leave at all. 19% of employed men with kids under six take no leave after a birth. Of the ones who do, half take two weeks or less. The OECD average for father-specific paid leave is a little over 13 weeks, and the US number is zero… not to mention the expectation and social pressure that is on employees in general today.

We rewrote the job description down to one word, present, and didn't change a single condition of employment. And then we act surprised that men feel, and arguably are... underwater.

Brodotype: Everyone agrees there's a gap in postpartum and midlife women's health. What's your uncomfortable take on how we've defined it?

Brody: Let’s ground ourselves with an example of what happens when one person in a family gets hit. Say the mother has postpartum depression. She gets a diagnosis, and if she's lucky she gets a referral and a plan, and that's good and necessary. But what happened to the family? Somebody is covering. Somebody is absorbing hours they didn't have… Somebody's kids are getting a thinner version of a parent for a year. Every diagnosis has a blast radius, and we treat the point of impact and walk away from the rest.

Turns out there’s a lot of research on this 🫣. Researchers Christakis and Allison looked at more than half a million elderly couples in the New England Journal and found that when a wife is hospitalized for dementia, her husband's risk of dying goes up 22%, and when a husband is hospitalized for psychiatric illness, his wife's goes up 32%. That isn't grief, the spouse is still alive. The illness itself is moving through the household. It runs the other way too. In the STAR*D-Child study, when mothers' depression went into remission, their kids' psychiatric diagnoses dropped about 11%, and nobody had treated the kids... they just got better because their mother got better.

We've known that for twenty years and built nothing on it, and I think the reason is that there's no chart to put it in. When researchers at Northwestern wanted to study families in the medical record, they had to reconstruct them out of emergency contact fields. A million people, 448,000 inferred families. We have to figure out that you have a family from who you wrote down to call in an emergency.

So the maternal gap is real and I'm not arguing against it. I personally didn't realize how large the gap when I started this post, but up to 40% of women never go to their postpartum visit which is shocking. More than half of pregnancy-related deaths happen after the birth, and 11.7% of them happen between six weeks and a year, after everyone has stopped paying attention. Mental health is the leading underlying cause, at 27.7%. All of that is true and underserved.

But I do kind of wonder if we've drawn the boundary in the wrong place. What if the real gap isn't maternal at all, and maternal health is just where the failure shows up first and loudest? A birth, a death, a cancer diagnosis, a job loss, a fire. Every one of those is a household event, and we process all of them as a series of unrelated individual encounters. Job loss is the cleanest example because nobody codes it as medical. Workers displaced in a mass layoff die at 50 to 100% higher rates the following year. And when a father loses his job, his kid's odds of fair or poor mental health go up about 1.1 percentage points, which is an 85% relative increase (thanks Claude). The kid didn't lose anything. The kid absorbed it.

And this is the tension I can't resolve. Naming it "maternal" is what finally got it money after decades of nothing. Naming it "family" is broad enough that it could quietly become nobody's problem again (or extremely expensive).

Brodotype: You're calling out a system for being too individualistic. Where do you catch yourself doing the exact same thing at home?

Brody: Constantly... that's the part of this that keeps me honest.

I don't tend my family. I tend the members of my family. I check on my wife, I check on my older kid, I check on the baby, and underneath that is an assumption I never really examined, which is that the family is the sum of its parts. If all four people are individually okay, then the thing itself must be okay.

I don't think that's how it works. A family is a unit on its own. It has a temperature and a rhythm and a way it holds weight or doesn't. And attention is zero-sum, so every time I turn toward one person I'm turning away from the others. What I've built isn't really a strategy, it's a rotation.

The thing that makes me wince is that I'd never run a team this way. I wouldn't tell you the org is healthy because I had four good one-on-ones. I'd ask what the team needs in order to function and then figure out what each person contributes to that or takes away from it. I'm pretty ruthless about that distinction at work. At home I default to triage.

So the critique cuts both ways. The healthcare system is individualistic because we are. It reflects a culture that believes a family is four people who happen to share an address, and that if you take care of the people, the family takes care of itself. I've been carrying that exact assumption around inside my own house while writing about how wrong it is.

Brodotype: So what do you do when there isn't a path?

Brody: I have therapy. I have a few people I can say the real thing to. I have enough self-awareness, which I got late and mostly by force and a decade of practice, to notice when something is off before it turns into something else.

I want to be careful here, because there's a version of this where I'm the resourceful guy who found his own way and you should too, and that version is garbage. I'm sure of that because of something Maguire did...

He took 10% of his newsletter revenue and set up a fund so that any dad struggling with his mental health after a birth could get five therapy sessions paid for. He posted a donation link and a Google form for requests. He was flooded with donations!!! Not a single request for assistance.

The money was there. The stigma had already been broken by the guy asking, who'd written publicly about his own collapse. His read on it was that he was asking men to do two hard things at once, admit they needed help with their mental health and admit they needed help with money. Which, if you think about the three anchors, is two of them given up in a single form submission - he started with an already losing formula.

That's what we're up against, and it's why "just ask for help" isn't a health policy. Even when somebody removes every barrier and hands you the thing for free, the hand doesn't go up... because they don't even really know it yet. Or if they do - the acknowledgment is taboo.

Which is the argument for building systems that don't wait for the hand. Finland gives every family eleven to fifteen visits at a neighborhood clinic and explicitly names the whole family, fathers included, as the thing being supported. The Netherlands sends a maternity aide into your house for eight to ten days after a birth, and part of her job is cleaning your bathroom. In the Nurse-Family Partnership trials, mothers who got prenatal and postpartum home visits had a two-decade mortality rate of 0.4%, against 3.7% in the control group.

The role of a father is changing faster than it ever has, and so is the role of a parent and the shape of a family, all of it accelerating along with everything else. My brain rewired itself this spring.... and the system that's supposed to catch us doesn't know any of that happened.